Académique Documents
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PATIENT DATA
SUBJECTIVE EXAMINATION
Chief complaints
History of trauma
Surgical history
Date of surgery Type of incision/ surgery Type of fixation- k-wire/ intra-medullary/ external nailing Relevant to the problem any previous history
Past history
Degenerative disease
Medical history
h/o diabetic, hypertensive, epileptic or cancer What are the drugs presently taking Smoking/ alcoholic (it can increase the healing time) Poor/ medium/ high income group
Drug history
Personal history
Socio-economic status
PAIN ASSESSMENT
Onset
Sudden/gradual
Aching Dull-aching
Character
Continuous/ intermittent
Traumatic/ degenerative
Nature
OBJECTIVE EXAMINATION
Vital signs
Blood pressure Pulse rate Respiratory rate Body temperature Body built
On observation
Oedema Colour of the skin (any signs of circulatory complication) Any infection Presence of any open wound/ surgical incision Mobility level of the patient Deformity Muscle atrophy Presence of any external device Psychological status
On palpation
Pulse
Upper
limb- axillary and radial pulse Lower limb- femoral and dorsalis pedis
Edema Warmth Tenderness
On examination
Range
Muscle
of motion
passive/ end feel
Active/
Ligamentous stretch
Hard
Firm
Hard
Empt y
Strength of crutch muscles (in lower limb fracture) Respiratory assessment (post surgical)
Berating pattern Chest wall movement Any signs of infection (sputum with yellow colour)
Scar type Scar length Location
Scar assessment
Assessment of posture Assessment of gait (in lower limb fracture) Examination of ADL
PROBLEM LIST
Pain Edema Reduced ROM Reduced muscle power Muscle wasting Deformity/ tightness Abnormal scarring Chest complication (post surgery) Change in posture Gait disturbance Difficulty ADL Psychological problem
GOALS
reduce pain To reduce edema To normalize muscle power To prevent muscle wasting To prevent/ reduce tightness To prevent deformity To prevent chest complication
correct deformity To correct posture To correct gait To improve ADL To give psychological support to he patient